Financial Policies

The Center for Innovative GYN Care is committed to excellent patient care. The following guidelines will provide you with specific information regarding our financial policies. We believe that your understanding of these policies is important to our professional relationship.

FINANCIAL POLICIES

Co-Pays, Deductibles, and Fees: All co-payments, insurance deductibles, and fees for services not covered by your insurance policy are due at the time service is rendered. For your convenience, our office accepts cash, personal checks, Visa and MasterCard.

Appointment Cancellations: Once your appointment has been scheduled, cancellation of your appointment within the same day or due to no show will result in a cancellation fee of up to $75. All cancellations must be made at least 24 hours prior to your scheduled appointment.

Surgery Cancellations: Once your procedure has been scheduled, cancellation of your surgery (for any reason other than medical illness) will result in a $1,000.00 cancellation fee. This fee will be waived if the cancellation occurs prior to 7 days before surgery.

Returned Checks: A $35.00 returned check service charge will be applied for a dishonored check. This service charge is in addition to any other amount due. This fee is not billed to your insurance company and must be taken care of prior to your next appointment.

Disability and/or FMLA Forms: You will be charged $25 completion for the first 3 pages, additional charges may apply for additional pages or information. This charge must be paid before your paperwork is processed. We will complete this request within seven to ten business days.

Past due balances: Outstanding balances are due within 30 days, unless prior arrangements have been made with the billing department. Seriously past due accounts or those failing to honor the agreed-upon payment terms will be sent to a collection agency. If your account is sent to collections, a 33% fee will be added to the outstanding balance along with any other collection fees incurred. You must pay all past due amounts before subsequent appointments can be scheduled. In addition, payment in full will be expected at the time of service for any future services.

Insurance Coverage: Your health insurance is an agreement between you and your insurance company. They will provide you with an EOB (Explanation of Benefits) to explain the services they cover. Please inquire to the receptionist and/or billing department to ensure the provider participates with your plan. If the provider participates with your insurance company, all services performed in our office and at the hospital will be billed directly to the insurance company unless we have received prior notification of non-covered services. All co-pays and deductibles are your responsibility. Co-pays are due at the time of the visit. Deductibles will be billed to you. We will not be able to bill an insurance company that we do not participate in, nor can we accept payment from them as payment for services performed.

If we do not participate with your insurance company and you have out-of-network benefits, you may receive a check directly from the insurance company for services performed. You must turn this payment over to The Center for Innovative GYN Care along with a copy of the Explanation of Benefits. We will not balance bill for any amounts not covered with the out-ofnetwork benefit as long as the payment you receive is given in full to The Center for Innovative GYN Care.

Please have your insurance card available at each office visit. Inform the receptionist if you have had a change in insurance since your last visit so we can bill the appropriate parties. Any balance not covered by the insurance company becomes your responsibility. Payment for office visits is due at the time of the visit. We will provide you with an itemized bill so that you may submit the charges to your insurance company.

Referrals: If your insurance requires a referral, it is your responsibility to obtain one prior to your appointment. The providers at The Center for Innovative GYN Care are considered Specialists, therefore if you have an HMO or POS plan, please be sure to bring an insurance referral with you to your scheduled appointments. You will need to contact your Primary Care Physician to obtain your referral. You will be responsible for payment for services rendered without a referral (if required). If a referral is not presented at the time of service, you will be responsible for payment in full for those services not covered.

Please contact our billing department if you have specific questions or concerns. When calling, please have your account number available so that we may serve you more efficiently.

I have read and fully understand the financial policy set forth by The Center for Innovative GYN Care and I agree to the terms of the Financial Policy. I understand that the terms of the policy may be amended by The Center for Innovative GYN Care at any time without prior notification.